All bathwater and no baby: revisiting a national curriculum and state examination for nursing?

Thompson, David R. and Watson, Roger (2005) All bathwater and no baby: revisiting a national curriculum and state examination for nursing?. Nurse Education Today, 253: 165-249. doi:10.1016/j.nedt.2004.11.002

Nurse education in the United Kingdom (UK) has undergone dramatic changes in the last decade and is now wholly located within the higher education (HE) sector. We have argued elsewhere that, whilst this has largely been welcomed, it is not without its problems and nursing is in danger of losing its way (Thompson and Watson, 2001, Watson and Thompson, 2000 and Watson and Thompson, 2004). There is a certain irony in the fact that being located in the HE sector has actually deprived nursing of its funding from the HE funding bodies. Instead, nursing in the HE sector has been funded, albeit indirectly, from NHS resources through the workforce development confederations and directorates who exerted tight control over the delivery of nurse education and, in some cases, deprived university nursing departments of their research infrastructure funding.

The mission of a university could be described as the acquisition, assessment and dissemination of knowledge. Teaching and learning, and their assessment, are issues that concern us. Many nurses hold educational qualifications and are more familiar with pedagogical principles than many of their university colleagues. However, it seems to us incongruous that university departments of nursing, who are educating and training nurses to work across regional, national and international boundaries, determine their own curricula and examinations to test them. It simply does not make sense. Perhaps, as is so common in the history of the discipline, nursing threw out the baby with the bathwater. Prior to the mid-1990s, the national bodies determined a national curriculum and state examination. This, despite its flaws, at least appeared to be fair and equitable.

We all know that universities and departments vary considerably in terms of quality of education, and no-one really believes that degree standards are the same across the whole higher education sector. Other countries, such as the USA and Hong Kong, maintain standard pre-registration examinations for nursing. By these means it is truly possible to compare the quality of teaching and learning across departments; expensive quality assurance (QA) procedures become redundant – simply measure the outcomes. The potential savings for UK university departments of nursing in terms of costly QA procedures can only be imagined.

With the vagaries of funding, and the huge cost in terms of time and resources as well as the difficulty in getting numerous people across the country to serve as external examiners, it seems nonsensical, to say the least, to maintain the present system. Each university department of nursing in the UK spends vast amounts of time and money on designing curricula, delivering syllabi and participating in regulatory activities. The present situation represents a ‘zero sum game’ whereby increases in activity such as increasing numbers of students or expanding the curriculum requires greater amounts of curriculum design and regulatory activity. The alternative represents a situation whereby everybody wins: precious NHS resources could be redirected towards patient care and precious time could be directed by academic nurses towards research.

There is real merit in having a national curriculum – and a state examination to test it. A national curriculum designed, developed and reviewed to meet contemporary and universal demands is required. At least a core curriculum is warranted. It must take account of changes in teaching, learning and assessment. Active learning techniques, such as problem-based, inquiry-based, cooperative and evidence-based learning, should be integrated into the curriculum. Learning outcomes should be made explicit. There are opportunities to exploit e-learning on Intranet sites, and simulators, in both undergraduate and postgraduate education. Assessment systems need to be robust but flexible.

Assessing clinical competence is problematic (Watson et al., 2002) but, in terms of clinical course components, core skills could be assessed by performance in the use of a common objective structured clinical examination (OSCE). Whilst not without problems of ecological validity and performance issues, these have proved highly successful in medicine (Watson et al., 2002 R. Watson, A. Stimpson, A. Topping and D. Porock, Clinical competence assessment in nursing: a systematic review of the literature, Journal of Advanced Nursing 39 (2002), pp. 421–431. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (59)Watson et al., 2002) and, at least, provide the opportunity to test the same knowledge and skills in the same way across the curriculum and across the country.

A national curriculum and a state examination is more likely to ensure the provision and standards of awards in nursing are being safeguarded and enhanced. This also permits national benchmarking of standards for nursing education – something that has taxed the profession in recent years (Quality Assurance Agency for Higher Education, 2001). We can already hear the rejoinders about ‘erosion of academic freedom’ and ‘turning the clock back’. However, nursing education in the UK must face the fact that we have precious little of the former and that the only solution may be the latter.